Current through Register Vol. 50, No. 9, September 20, 2024
A. In order to assure timely and appropriate
care for applicants, the level II authority may make an advance group
determination by category that takes into account that certain diagnoses,
levels of severity of illness or need for a particular service clearly
indicates the need for nursing facility admission or that the provision of
specialized services is not normally needed. The applicable level II authority
may make an advance group determination that nursing facility care is needed
for persons in the following categories.
1.
Convalescent Care. If an applicant appears to be in need of level II assessment
but is hospitalized for a serious illness and needs time to convalesce before a
valid level II assessment can be performed, provisions may be made for
temporary medical certification for nursing facility care. The maximum period
of time that a level II assessment may be delayed is 100 days. The period of
convalescence allowed will be consistent with the diagnosis and medical
condition of the individual.
2.
Terminal Illness. Terminally ill applicants, who are not a danger to themselves
or others, may be categorically approved for nursing facility admission. This
categorical eligibility determination is valid for six months at a time, in
accordance with the definition of terminal illness used for hospice purposes,
and remains valid as long as the applicant's mental condition does not create a
barrier to receiving the necessary nursing facility services.
3. Severe Physical Illness. Severely ill
applicants, who are not a danger to themselves or others and whose medical
condition prevents them from engaging in specialized services, may be
categorically approved for nursing facility admission. The attending physician
shall determine that the applicant is unable to benefit from specialized
services due to the severe level of physical impairment. This categorical
determination also remains valid for six months to allow for an individualized
assessment of the resident's needs. Severe physical conditions considered in
this category include, but are not limited to:
a. coma;
b. ventilator dependence;
c. functioning at a brain stem
level;
d. advanced chronic
obstructive pulmonary disease;
e.
Parkinson's disease;
f.
Huntington's disease;
g.
amyotrophic lateral sclerosis; and
h. congestive heart failure.
4. Provisional Admissions
a. An applicant who is not a danger to
himself or others, but who exhibits symptoms of delirium, may be categorically
approved for nursing facility admission pending further assessment when the
delirium clears and an accurate diagnosis can be made. This categorical
determination may be valid for a period not to exceed 30 days.
b. An applicant who is in an emergency
situation and requires protective services may be categorically approved for
nursing facility admission pending further assessment. This categorical
determination may be valid for a period not to exceed seven days.
5. Respite Care. An applicant who
qualifies for nursing facility care and is not a danger to self or others, but
resides at home with care from a family member or other caregiver, may be
categorically approved for admission in order to provide respite to the in-home
caregiver. Respite provides relief to the caregiver when that individual is
unable to provide care for a short period of time.
6. Dementia/ID. This category applies to
applicants who are intellectually disabled or have indications of intellectual
disability, but also exhibit symptoms associated with dementia. These
individuals require supervision in a structured environment and a planned
program of activities. This categorical determination may remain valid for a
period not to exceed one year or until such time that the level II authority
makes a determination that an alternative placement is more
appropriate.
B. Although
an advanced group determination may be made at admission, the applicable level
II authority must still make a determination regarding the need for specialized
services (based on an individual evaluation) for continuation of
stay.
C. In each case that
specialized services are determined not to be necessary, it remains the
responsibility of the nursing facility to notify the appropriate agency if the
resident's mental condition changes and becomes a barrier to utilizing nursing
facility services, or the resident becomes a danger to himself or
others.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
